2021 Changes for Evaluation and Management
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Discussion Points • What E&M codes will be impacted • Elimination of history and exam as required components • Changes to the MDM grid • Case study
Evaluation and Management Services Office or Outpatient Non-Face-to-Face Hospital Observation Special E&M Services Hospital Inpatient Newborn Care Services Consultations Delivery/Birthing Room Attendance and Resuscitation Emergency Department Inpatient Neonatal Intensive Care & Peds & Neonatal Critical Care Critical Care Cognitive Assessment Care Plan Nursing Facility Care Management Domiciliary, Rest Home or Custodial Care Pyschiatric Collaborative Care Management Home Visits Transitional Care Management Prolonged Services Advanced Care Planning Case Management General Behavioral Health Integration Care Management Care Plan Oversight Unlisted E&M Preventative Medicine
The E&M Guidelines Who made this stuff up? • The guidelines are intended to explain in further detail the process for determining an appropriate level of service for patient visits. • The E&M Guidelines were first developed by CMS in 1995. • Guidelines were revised in 1997 to better benefit specialties. • 2021 will be the first update in 24 years.
Key Components Time History Exam MDM Medical Necessity
Elements of Medical Decision Making 2021 MDM Elements (2 of 3 required) Current MDM Elements (2 of 3 required) Number and Complexity of Problems Addressed Number of Diagnoses of Treatment Options Amount and/or Complexity of Data to be Reviewed and Analyzed Amount of Complexity of Data Reviewed Risk of Complications and/or Morbidity or Risk of Complications and/or Morbidity or Mortality Mortality or Patient Management
MEDICAL DECISION MAKING Number and Complexity Of Problems Addressed Minimal • 1 self-limited or minor problem • 2 or more self-limited or minor problems; OR Low • 1 stable chronic illness; OR • 1 acute, uncomplicated illness or injury • 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment; OR • 2 or more stable chronic illnesses; OR Moderate • 1 undiagnosed new problem with uncertain prognosis; OR • 1 acute illness with systemic symptoms; OR • 1 acute complicated injury • 1 or more chronic illnesses with severe exacerbation, High progression, or side effects of treatment; OR • 1 acute or chronic illness or injury that poses a threat to life or bodily function
MEDICAL DECISION MAKING Amount and/or Complexity of Data to be Reviewed and Analyzed Minimal Minimal or none Category 1: Tests and documents • Any combination of 2 from the following: • Review of prior external note(s) from each unique source*; Limited • review of the result(s) of each unique test*; (Must meet the requirements of • ordering of each unique test* OR at least 1 of the 2 categories) Category 2: Assessment requiring an independent historian(s) (For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high) Category 1: Tests, documents, or independent historian(s) • Any combination of 3 from the following: • Review of prior external note(s) from each unique source*; • Review of the result(s) of each unique test*; Moderate (Must meet the • Ordering of each unique test*; requirements of at least 1 out of • Assessment requiring an independent historian(s) OR 3 categories) Category 2: Independent interpretation of tests • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported); OR Category 3: Discussion of management or test interpretation • Discussion of management or test interpretation with externa Category 1: Tests, documents, or independent historian(s) • Any combination of 3 from the following: • Review of prior external note(s) from each unique source*; • Review of the result(s) of each unique test*; • Ordering of each unique test*; Extensive (Must meet the • Assessment requiring an independent historian(s) OR requirements of at least 2 out of Category 2: Independent interpretation of tests 3 categories) • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported); OR Category 3: Discussion of management or test interpretation • Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)
RISK OF COMPLICATIONS OF MORBIDITY/ MORTALITY
MEDICAL DECISION MAKING Amount and/or Complexity of Data to be Reviewed and Analyzed Minimal Minimal risk of morbidity from additional diagnostic testing or treatment Low Low risk of morbidity from additional diagnostic testing or treatment Moderate risk of morbidity from additional diagnostic testing or treatment Examples only: • Prescription drug management • Decision regarding minor surgery with identified patient or procedure risk factors Moderate • Decision regarding elective major surgery without identifiedpatient or procedure risk factors • Diagnosis or treatment significantly limited by social determinants of health High risk of morbidity from additional diagnostic testing or treatment Examples only: • Drug therapy requiring intensive monitoring for toxicity High • Decision regarding elective major surgery with identified patient or procedure risk factors • Decision regarding emergency major surgery • Decision regarding hospitalization • Decision not to resuscitate or to de-escalate care because of poor prognosis
MEDICAL DECISION MAKING To qualify for a particular level of medical decision making, two of the three elements for that level of medical decision making must be met or exceeded. Number and Complexity of A Problems Addressed N/A Minimal Low Moderate High Amount and/or Complexity of Data to be Reviewed and B Analyzed N/A Minimal Limited Moderate Extensive Risk of Complications and/or Morbidity or Mortality of C Patient Management N/A Minimal Low Moderate High Level of Service Level 1 Level 2 Level 3 Level 4 Level 5
Time CPT Current Time 2021 Time 99201 10 Ø 99202 20 15-29 99203 30 30-44 99204 45 45-59 99205 60 60-74 99211 5 Minimal 99212 10 10-19 99213 15 20-29 99214 25 30-39 99215 40 40-54
Total Time Total time on the date of the encounter (office or other outpatient services [99202- 99205, 99212- 99215]): For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff).
Physician/other qualified health care professional time includes the following activities, when performed: • Preparing to see the patient (eg, review of tests) • Obtaining and/or reviewing separately obtained history • performing a medically appropriate examination and/or evaluation • Counseling and educating the patient/family/caregiver • Ordering medications, tests, or procedures • Referring and communicating with other health care professionals (when not separately reported) • Documenting clinical information in the electronic or other health record • Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver • Care coordination (not separately reported)
Prolonged Clinical Staff Services With Physician or Other Qualified Health Care Professional Supervision Total Duration of Prolonged Code(s) Services less than 45 minutes Not reported separately 45-74 minutes (45 minutes - 1 hr. 99415 X 1 14 min.) 75-104 minutes (1 hr. 15 min. - 1 99415 X 1 AND 99416 X 1 hr. 44 min.) 105 or more (1 hr. 45 min. or 99415 X 1 AND 99416 X 2 or more more) for each additional 30 minutes.
Prolonged Service With or Without Direct Patient Contact on the Date of an Office or Other Outpatient Service Total Duration of Code(s) Total Duration of Code(s) Prolonged Services Prolonged Services New Patient Established Patient less than 75 minutes Not reported separately less than 55 minutes Not reported separately 75-89 minutes 99205 X 1 and 55-69 minutes 99215 X 1 and 99417 X 1 99417 X 1 70-84 minutes 99215 X 1 and 99417 X 2 90-104 minutes 99205 X 1 and 99417 X 2 85 or more 99215 X 1 and 99417 X 3 105 or more 99205 X 1 and 99417 X or more for each 3 or more for each additional 15 minutes. additional 15 minutes.
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